All therapy services are confidential by Federal Laws and regulations and personal information will not be released unless: 1) you give written consent, 2) information is required by a court order, 3) disclosure is necessary for a medical emergency. I may be required by law to breach confidentiality and notify the appropriate individuals or authorities in the following situations: 1) if there are, in my judgement, indications that you present a clear and serious threat to the welfare of either yourself or someone else, 2) if there is evidence of child abuse and/or physical or sexual abuse to any dependent care population. Other than those exceptions, whatever you discuss with me is confidential, and will not be disclosed to anyone, including friends and family, unless you sign a written release of information. As part of clinical supervision, case material may be presented but your name will not be used.

All clients are required to give at least 24 hours notice when canceling or rescheduling appointments with me. Except in cases of emergency, any client who does not give at least 24 hours notice before canceling or rescheduling, or who does not give any notice at all and does not make their scheduled appointment, may be charged for the missed session. Clients who have copays for their appointments may be charged their full copay for each missed visit. Clients who do not pay copays may be charged $15 for each missed visit. Only clients who have Medicare or Medical Assistance coverage or who are using their EAP (Employee Assistance Program) benefits will not be charged for missed visits.

All clients are expected to be on time for their scheduled appointments. Anyone who shows up more than 20 minutes late for their appointment will not be seen and will be charged for the missed visit, so please make all efforts to show up on time for your appointments.

I do not like having to charge clients for sessions that they are not using. I also do not like saving an appointment slot for someone who keeps missing their appointments. Therefore, it is extremely important that you keep your scheduled appointments on time or make every effort to contact me at least 24 hours ahead of time. Clients who consistently miss appointments may have their cases closed, as it is unfair to take up a space that can be used by someone else seeking help and willing to attend regularly.

By dated signature below, I give my informed consent to accepting therapy services in accord with orientation information provided in writing and verbally. I agree with the Treatment Plan, which Margaret Andem, LCSW and I will update periodically. I have a right to receive a copy of any forms that I sign. I understand that my participation is strictly voluntary. I have a right to discuss, question, or even refuse any service at any time.

I understand that Ms. Andem’s ability to reduce or waive fees is at all times contingent upon the availability of funds from financial supporters.

I agree to verify and maintain my eligibility for services provided by third party payors by completing applications, claim forms, etc. as may be required by such payors. I agree to promptly inform Ms. Andem about any changes in my circumstances which may affect my continued eligibility for services, for example, income changes, change of residence, etc. and to provide such proof of my income as required.

I understand that I am ultimately responsible and liable to Ms. Andem for payment of any charges for services provided me. I may be charged if I receive services and am found ineligible for third party payment or for which my insurance claim is denied for any reason.